Significant Predictor Of 90-day Mortality Research Articles

The long-term impact of an antimicrobial stewardship program in febrile neutropenia: an 8 years follow up.

To describe the long-term effects of an ASP among febrile neutropenia (FN) patients. A quasi-experimental study was conducted between 2015 and 2023 at a tertiary care hospital in Istanbul, Türkiye. The ASP was implemented for FN patients, and the effects were assessed before and after the ASP interventions, which included FN clinical pathways and regular multi-disciplinary meetings with relevant healthcare workers. A total of 489 FN episodes of 290 patients were included, 42% were female, and the mean age was 56 years (SD: 15, range: 18-89 years). After the intervention, the rate of appropriate antimicrobial therapy at the levels of starting (p = 0.005), switching (p < 0.001), and de-escalation/discontinuation, (p < 0.001) significantly increased. Another positive impact of the ASP was a significant reduction in candidemia (from 4.88 to 0.74, p = 0.004), as well as a significant reduction in the 90-day mortality rate (from 19 to 5%, p < 0.001). In multivariate analysis, having a gram-negative bloodstream infection, prolonged days with fever, and a high risk for neutropenia were found to be significant predictors of 90-day mortality, while follow-up with ASP significantly reduced mortality. Implementation of ASP led to reduced candidemia and LOS without increasing mortality, even in a country with a high rate of antimicrobial resistance. Implementation of sustainable ASP for FN patients is critical in combating antimicrobial resistance.

New scoring system as predictor of 90-day mortality in appendicular skeletal metastases

Introduction. Cancer is one of the most common causes of death worldwide and occurs through the ability of malignant neoplasm cells to leave the primary tumor site and spread to other parts of the body through a complex process known as metastases. However, the decision to do surgery is dilemmatic due to the surgical risk, mortality rate, and cost control, especially in a developing country. Material and methods. A case control was investigated in our tertiary referral hospital from patients in 2013–2021. Of the 113 eligible patients, 24% (27) patients died within 3 months of their fracture. Medical records were reviewed in detail specifically for patient’s age, Karnofsky score, Lactate Dehydrogenase (LDH), C-Reactive Protein (CRP), types of the primary tumor, and metastases to another organ. Chi-square followed by multivariate analysis using backward elimination method were performed. Further ROC analysis was done to assess the sensitivity and specificity of the novel scoring system. Results. High CRP, LDH, and additional metastases to another organ besides the bone are the significant predictors of 90-day mortality after a pathological fracture due to bony metastases. A total score of 5 or lower has 78% specificity to predict a 90-day mortality after a pathological fracture due to bony metastases. Conclusions. Focus to palliative should not be commenced when a total score of 5 or lower is found. Future prospective multicenter studies would help establish the validity of this novel scoring system.

Predictive Relevance of Baseline Lactate and Glucose Levels in Patients with Spontaneous Deep-Seated Intracerebral Hemorrhage.

(1) Background: As elements of the standard admission blood panel, lactate and glucose represent potential biomarkers for outcome prediction. In patients with intracranial hemorrhage (ICH), data on the predictive value of these blood values is exceedingly sparse. (2) Methods: Between 2014 and August 2020, all patients with deep-seated ICH referred to the neurovascular center at the authors’ institution were included in the subsequent study. Serum levels of lactate and glucose at the time of admission were compared with mortality at 90 days. In addition, a multivariate analysis was performed in order to identify independent admission predictors for 90-day mortality. (3) Results: Among the 102 patients with deep-seated ICH, elevated lactate and glucose levels on admission were significantly associated with increased mortality at 90 days. Multivariate logistic regression analysis identified “ICH score ≥3” (p = 0.004) along with “admission hyperlactatemia” (p = 0.025) and “admission hyperglycemia” (p = 0.029) as independent and significant predictors of 90-day mortality in patients with deep-seated ICH. (4) Conclusions: Initially elevated lactate and glucose levels after spontaneous intracerebral hemorrhage are associated with poor outcome, suggesting a potential application for future prognostic models when considered in conjunction with other parameters.

Predictors of 30-day and 90-day mortality among hemorrhagic and ischemic stroke patients in urban Uganda: a prospective hospital-based cohort study

BackgroundWe report here on a prospective hospital-based cohort study that investigates predictors of 30-day and 90-day mortality and functional disability among Ugandan stroke patients.MethodsBetween December 2016 and March 2019, we enrolled consecutive hemorrhagic stroke and ischemic stroke patients at St Francis Hospital Nsambya, Kampala, Uganda. The primary outcome measure was mortality at 30 and 90 days. The modified Ranking Scale wasused to assess the level of disability and mortality after stroke. Stroke severity at admission was assessed using the National Institute of Health Stroke Scale (NIHSS) and Glasgow Coma Scale (GCS). Examination included clinical neurological evaluation, laboratory tests and brain computed tomography (CT) scan. Kaplan-Meier curves and multivariate Cox proportional hazard model were used for unadjusted and adjusted analysis to predict mortality.ResultsWe enrolled 141 patients; 48 (34%) were male, mean age was 63.2 (+ 15.4) years old; 90 (64%) had ischemic and 51 (36%) had hemorrhagic stroke; 81 (57%) were elderly (≥ 60 years) patients. Overall mortality was 44 (31%); 31 (23%) patients died within the first 30 days post-stroke and, an additional 13 (14%) died within 90 days post-stroke. Mortality for hemorrhagic stroke was 19 (37.3%) and 25 (27.8%) for ischemic stroke. After adjusting for age and sex, a GCS score below < 9 (adjusted hazard ratio [aHR] =3.49, 95% CI: 1.39–8.75) was a significant predictor of 30-day mortality. GCS score < 9 (aHR =4.34 (95% CI: 1.85–10.2), stroke severity (NIHSS ≥21) (aHR = 2.63, 95% CI: (1.68–10.5) and haemorrhagic stroke type (aHR = 2.30, 95% CI: 1.13–4.66) were significant predictors of 90-day mortality. Shorter hospital stay of 7–13 days (aHR = 0.31, 95% CI: 0.11–0.93) and being married (aHR = 0.22 (95% CI: 0.06–0.84) had protective effects for 30 and 90-day mortality respectively.ConclusionMortality is high in the acute and sub-acute phase of stroke. Low levels of consciousness at admission, stroke severity, and hemorrhagic stroke were associated with increased higher mortality in this cohort of Ugandan stroke patients. Being married provided a protective effect for 90-day mortality. Given the high mortality during the acute phase, critically ill stroke patients would benefit from early interventions established as the post-stroke- standard of care in the country.

Delayed removal of a percutaneous left ventricular assist device for patients undergoing catheter ablation of ventricular tachycardia is associated with increased 90-day mortality

Assess if timing of removal of a percutaneous left ventricular assist device (pLVAD) after ventricular tachycardia (VT) ablation alters patient outcomes. Sixty-nine patients underwent pLVAD support. Patients were divided into early (< 24h, n= 43) and delayed (≥ 24h, n= 26) removal groups after ablation. Factors for delayed pLVAD removal and predictors of 90-day mortality were analyzed. The delayed removal group had lower LVEF (27.1 ± 9.3% vs. 20.6 ± 5.4%, p = 0.002), greater percentage LVEF < 25% (58.1% vs. 84.6%, p = 0.02), and more VT storm (41.9% vs. 96.2%, p < 0.001). Ventricular fibrillation (VF) was induced in 9/69 (13%), with incidence higher in delayed removal group (27% vs. 5%, p = 0.002). VT storm (OR = 34.72, 95% CI, 4.30-280.33; p = 0.001), LVEF < 25% (OR = 3.95, 95% CI, 1.16-13.48; p = 0.03), and VF induced during ablation (OR = 9.25, 95% CI, 1.71-50.0; p = 0.01) were associated with delayed pLVAD removal in univariate analysis. Delayed pLVAD removal had a significantly higher 90-day mortality rate (2.3% vs 30.2%; p < 0.001). Univariate Cox proportional hazard regression analysis revealed delayed pLVAD removal was a significant predictor of 90-day mortality. Prolonged pLVAD insertion (≥24h) after VT ablation was associated with VT storm, LVEF < 25%, and VF induced during ablation. Delayed pLVAD removal was a significant predictor of 90-day mortality in patients undergoing VT ablation.

Outcomes of HIV-associated pneumocystis pneumonia at a South African referral hospital.

HIV-associated pneumocystis pneumonia (PCP) is increasingly recognized as an important cause of severe respiratory illness in sub-Saharan Africa. Outcomes of HIV-infected patients with PCP, especially those requiring intensive care unit (ICU) admission, have not been adequately studied in sub-Saharan Africa. The aim of this study was to describe the clinical phenotype and outcomes of HIV-associated PCP in a group of hospitalized South African patients, and to identify predictors of mortality. We conducted a retrospective record review at an academic referral center in Cape Town. HIV-infected patients over the age of 18 years with definite (any positive laboratory test) or probable PCP (defined according to the WHO/CDC clinical case definition) were included. The primary outcome measure was 90-day mortality. Logistic regression and Cox proportional hazards models were constructed to identify factors associated with mortality. We screened 562 test requests between 1 May 2004 and 31 April 2015; 124 PCP cases (68 confirmed and 56 probable) were included in the analysis. Median age was 34 years (interquartile range, IQR, 29 to 41), 89 (72%) were female, and median CD4 cell count was 26 cells/mm3 (IQR 12 to 70). Patients admitted to the ICU (n = 42) had more severe impairment of gas exchange (median ratio of arterial to inspired oxygen (PaO2:FiO2) 158 mmHg vs. 243 mmHg, p < 0.0001), and increased markers of systemic inflammation compared to those admitted to the ward (n = 82). Twenty-nine (23.6%) patients were newly-diagnosed with tuberculosis during their admission. Twenty-six (61.9%) patients admitted to ICU and 21 (25.9%) admitted to the ward had died at 90-days post-admission. Significant predictors of 90-day mortality included PaO2:FiO2 ratio (aOR 3.7; 95% CI, 1.1 to 12.9 for every 50 mgHg decrease), serum LDH (aOR 2.1; 95% CI, 1.1 to 4.1 for every 500 U/L increase), and concomitant antituberculosis therapy (aOR 82; 95% CI, 1.9 to 3525.4; P = 0.021). PaO2:FiO2 < 100 mmHg was significantly associated with inpatient death (aHR 3.8; 95% CI, 1.6 to 8.9; P = 0.003). HIV-associated PCP was associated with a severe clinical phenotype and high rates of tuberculosis co-infection. Mortality was high, particularly in patients admitted to the ICU, but was comparable to other settings. Prognostic indictors could be used to inform ICU admission policy for patients with this condition.

Role of percutaneous veno-arterial extracorporeal membrane oxygenation as bridge to left ventricular assist device.

Percutaneous veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides emergency circulatory support for cardiogenic shock patients and is used as a bridge to a left ventricular assist device (LVAD). The purpose of this study was to determine risk factors for LVAD implantation in patients who required percutaneous VA-ECMO as a bridge to long-term LVAD. We retrospectively investigated 32 consecutive LVAD patients who required percutaneous VA-ECMO as a bridge to long-term LVAD. Twenty-nine patients (91%) were intubated, and their serum creatinine and total bilirubin levels before LVAD implantation were 2.1±2.0 and 3.7±3.7mg/dl, respectively. Patients were supported by LVAD for 495±393days, during which 15 died, 6 recovered native cardiac functions and LVAD was explanted, and 11 underwent heart transplantation. Multivariate logistic regression analysis revealed that a preoperative left ventricular end-diastolic diameter (LVDd) ≤54mm was a significant predictor of 90-day mortality after LVAD implantation (OR 13.64; 95% CI 1.081-172.0; p=0.0433) and freedom from death during LVAD support was significantly worse in patients with an LVDd ≤54mm. Furthermore, preoperative LVDd was positively correlated with postoperative right ventricular stroke work index (r=0.739, p<0.0001) and patients with an LVDd ≤54mm had significantly worse postoperative right ventricular, renal, and hepatic functions. We demonstrated that percutaneous VA-ECMO could be utilized as a bridge to long-term LVAD in selected patients. Our results suggest that preoperative LVDd is a useful predictor of mortality and right ventricular function after LVAD implantation in patients requiring VA-ECMO, in whom assessment of right ventricular function is challenging.

Statistical Commentary

Brunelli and colleagues [1Brunelli A. Dinesh P. Woodcock-Shaw J. Littlechild D. Pompili C. Ninety-day mortality after video-assisted thoracoscopic lobectomy: incidence and risk factors.Ann Thorac Surg. 2017; 104: 1020-1026Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar] evaluate the factors associated with 90-day mortality in a cohort of 733 patients who underwent lobectomy by video-assisted thoracic surgery from 2012 to 2016. They report that Dlco (carbon monoxide lung diffusion capacity) below 60%, operative time longer than 2.5 hours, and male sex were statistically significant predictors of 90-day mortality. Despite a small sample size, the authors build a model to predict mortality from the coefficients in this data set. The purpose of such a model is for use in counseling patients and guiding treatment decisions. Like other models in cardiothoracic surgery, key concerns are a clear definition of the purpose of the model and its time of use in the clinical care pathway. In the current article, using operative time to counsel patients preoperatively has practical limitations, needing “what if” considerations. For a model to be most useful, all variables should be measured preoperatively if the purpose is to predict operative outcomes and use the tool in decision making. As described, the score cannot be developed and applied prospectively to counsel patients. Clear definition of purpose and the final application setting should help guide choices for factors considered in building a prediction model. The field of risk prediction has grown rapidly over the past decade. Although internal validation is more easily included in the model development phase, it leaves the user with concern about applicability in other settings. Risk models should be developed and then validated in a separate independent cohort before use in clinic. Extensive literature reports set forth the methods to follow through this process [2Moons K.G. Altman D.G. Vergouwe Y. Royston P. Prognosis and prognostic research: application and impact of prognostic models in clinical practice.BMJ. 2009; 338: b606Crossref PubMed Scopus (621) Google Scholar, 3Moons K.G. Kengne A.P. Grobbee D.E. et al.Risk prediction models: II. External validation, model updating, and impact assessment.Heart. 2012; 98: 691-698Crossref PubMed Scopus (678) Google Scholar, 4Moons K.G. Kengne A.P. Woodward M. et al.Risk prediction models: I. Development, internal validation, and assessing the incremental value of a new (bio)marker.Heart. 2012; 98: 683-690Crossref PubMed Scopus (568) Google Scholar]. Finally, presentation of the output from prediction models, scores, and scales is positioned as helping guide clinical decision making. Attention to how the scale is summarized for ease of use should again be a focus from early in the development. This can then ensure a presentation that is easy for patient and provider to comprehend, resulting in meaningful use for decision making. Ninety-Day Mortality After Video-Assisted Thoracoscopic Lobectomy: Incidence and Risk FactorsThe Annals of Thoracic SurgeryVol. 104Issue 3PreviewWe evaluated the incidence and risk factors of 90-day mortality rate after video-assisted thoracoscopic (VATS) lobectomy. Full-Text PDF

Clinical characteristics of atrial fibrillation-related cardioembolic stroke in patients aged 80 years or older.

Atrial fibrillation (AF)-related cardioembolic stroke is a serious problem in the aging society. The present study examined the clinical characteristics and outcomes of AF-related cardioembolic stroke in patients aged ≥80 years. Between September 2011 and April 2014, consecutive patients with ischemic stroke and AF were retrospectively extracted from the multicenter database. Clinical characteristics were compared between patients aged ≥80 years and <80 years. Multivariate cox proportional hazard models were used to estimate hazard ratios and 95% confidential intervals on 90-day mortality for age of ≥80 years. A total of 253 patients aged ≥80 years (87 men, 86.4 ± 5.0 years) and 196 patients aged <80 years (134 men, 70.4 ± 7.1 years) were included. Patients aged ≥80 years were more frequently female, and more likely to have higher premorbid modified Rankin Scale score (mRS), lower body mass index, previous history of stroke, prior antiplatelet therapy, congestive heart failure, and persistent AF. Patients aged ≥80 years had higher initial National Institutes of Health Stroke Scale score and were more likely to have occlusion of the cervicocephalic arteries, but less likely to receive thrombolysis. Patients aged ≥80 years had a higher mRS and mortality after 3 months. Age of ≥80 years was a significant predictor of 90-day mortality after adjustment for sex (hazard ratio 2.20, 95% confidential interval 1.25-4.09), but was no longer significant after further adjustment for other clinical characteristics and stroke severity. In AF-related cardioembolic stroke, patients aged ≥80 years had different clinical characteristics and poorer outcome compared with patients aged <80 years. Geriatr Gerontol Int 2017; 17: 708-713.

A Multi-Center International Study Assessing the Impact of Differences in Baseline Characteristics and Perioperative Care Following Radical Cystectomy.

Background: To identify potential avenues for quality improvement, we compared the variations in clinical practice and their association with perioperative morbidity and mortality following radical cystectomy (RC) for bladder cancer in the United States (US) and Japan.Methods: We reviewed our retrospectively collected database of 2240 patients who underwent RC for bladder cancer at the University of Michigan (n = 1427) and in 21 Japanese institutions (n = 813) between 1997 and 2014. We performed a systematic comparison of clinical and perioperative factors and assessed predictors of perioperative morbidity and mortality. Death within 90 days of surgery was the primary outcome.Results: There were apparent differences between the two study populations. Notably, US patients had a significantly greater BMI and higher ASA score. In Japanese institutions, median postoperative hospital stay was significantly higher (40 days vs. 7 days, p < 0.001) and 90-day readmission rates were significantly lower (0.6% vs. 26.8% , p < 0.001). There was a total of 1372/2240 (61.2%) patients with complications within 90 days and 66/2240 (2.9%) patient deaths. Significant predictors of 90-day mortality were older age (OR 1.04, CI 1.01–1.07), higher body mass index (OR 1.07, CI 1.02–1.12), node-positive disease (OR 3.14, CI 1.78–5.47), increased blood loss (OR 1.02, CI 1.01–1.03), and major (Clavien-grade 3 or greater) complication (OR 3.29, CI 1.88–5.71).Conclusion: Despite major differences in baseline characteristics and care of cystectomy patients between the two study populations, peri-operative mortality rates proved to be comparable. This data supports an exploration of non-traditional factors that may influence mortality after cystectomy.

Rate of Perihematomal Edema Expansion Predicts Outcome After Intracerebral Hemorrhage.

Intracerebral hemorrhage is a devastating disorder with no current treatment. Whether perihematomal edema is an independent predictor of neurologic outcome is controversial. We sought to determine whether perihematomal edema expansion rate predicts outcome after intracerebral hemorrhage. Retrospective cohort study. Tertiary medical center. One hundred thirty-nine consecutive supratentorial spontaneous intracerebral hemorrhage patients 18 years or older admitted between 2000 and 2013. None. Intracerebral hemorrhage, intraventricular hemorrhage, and perihematomal edema volumes were measured from CT scans obtained at presentation, 24-hours, and 72-hours postintracerebral hemorrhage. Perihematomal edema expansion rate was the difference between initial and follow-up perihematomal edema volumes divided by the time interval. Logistic regression was performed to evaluate the relationship between 1) perihematomal edema expansion rate at 24 hours and 90-day mortality and 2) perihematomal edema expansion rate at 24 hours and 90-day modified Rankin Scale score. Perihematomal edema expansion rate between admission and 24-hours postintracerebral hemorrhage was a significant predictor of 90-day mortality (odds ratio, 2.97; 95% CI, 1.48-5.99; p = 0.002). This association persisted after adjusting for all components of the intracerebral hemorrhage score (odds ratio, 2.21; 95% CI, 1.05-4.64; p = 0.04). Similarly, higher 24-hour perihematomal edema expansion rate was associated with poorer modified Rankin Scale score in an ordinal shift analysis (odds ratio, 2.40; 95% CI, 1.37-4.21; p = 0.002). The association persisted after adjustment for all intracerebral hemorrhage score components (odds ratio, 2.07; 95% CI, 1.12-3.83; p = 0.02). Faster perihematomal edema expansion rate 24-hours postintracerebral hemorrhage is associated with worse outcome. Perihematomal edema may represent an attractive translational target for secondary injury after intracerebral hemorrhage.

MP06-19 A MULTI-CENTER INTERNATIONAL STUDY ASSESSING THE IMPACT OF DIFFERENCES IN BASELINE CHARACTERISTICS AND PERIOPERATIVE CARE FOLLOWING RADICAL CYSTECTOMY

You have accessJournal of UrologyBladder Cancer: Epidemiology & Evaluation II1 Apr 2016MP06-19 A MULTI-CENTER INTERNATIONAL STUDY ASSESSING THE IMPACT OF DIFFERENCES IN BASELINE CHARACTERISTICS AND PERIOPERATIVE CARE FOLLOWING RADICAL CYSTECTOMY Takahiro Osawa, Cheryl T. Lee, Takashige Abe, Norikata Takada, Khaled S. Hafez, Jeffrey S. Montgomery, Alon Z. Weizer, Brent K. Hollenbeck, Ted A. Skolarus, Sachiyo Murai, Nobuo Shinohara, and Todd M. Morgan Takahiro OsawaTakahiro Osawa More articles by this author , Cheryl T. LeeCheryl T. Lee More articles by this author , Takashige AbeTakashige Abe More articles by this author , Norikata TakadaNorikata Takada More articles by this author , Khaled S. HafezKhaled S. Hafez More articles by this author , Jeffrey S. MontgomeryJeffrey S. Montgomery More articles by this author , Alon Z. WeizerAlon Z. Weizer More articles by this author , Brent K. HollenbeckBrent K. Hollenbeck More articles by this author , Ted A. SkolarusTed A. Skolarus More articles by this author , Sachiyo MuraiSachiyo Murai More articles by this author , Nobuo ShinoharaNobuo Shinohara More articles by this author , and Todd M. MorganTodd M. Morgan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2180AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To identify potential avenues for quality improvement, we compared the variations in clinical practice and their association with perioperative morbidity and mortality following radical cystectomy (RC) for bladder cancer in the United States (US) and Japan. METHODS We reviewed our retrospectively collected database of 2240 patients who underwent RC for bladder cancer at the University of Michigan (n=1427) and in 21 Japanese institutions (n=813) between 1997 and 2014. We performed a systematic comparison of clinical factors and perioperative factors and assessed predictors of perioperative morbidity and mortality. Death within 90 days of surgery was the primary outcome. RESULTS There were a number of apparent differences in between the two study populations (Table 1). Notably, patients treated at the US institution had a significantly greater BMI and higher ASA score. The median postoperative hospital stay was significantly higher at the Japanese institutions (40 days vs. 7 days, p<0.001), and 90-day readmission rates were also significantly lower at the Japanese institutions (0.6% vs. 26.8%, p<0.001). There were a total of 1372/2240 patients (61.2%) with complications within 90 days and 66/2240 patients (2.9%) deaths. Significant predictors of 90-day mortality were older age (OR 1.04, CI 1.01-1.07), higher body mass index (OR 1.07, CI 1.02-1.12), node-positive disease (OR 3.14, CI 1.78-5.47), increased blood loss (OR 1.02, CI 1.01-1.03), and major (Clavien-grade 3 or greater) complication (OR 3.29, CI 1.88-5.71). Significant predictors of major complications were higher body mass index (OR 1.04, CI 1.02-1.07), higher ASA score (OR 1.35, CI 1.02-1.80), greater number of comorbidities (OR 1.33, CI 1.04-1.69), form of urinary diversion (p=0.001), increased estimate blood loss (OR 1.02, CI 1.01-1.03) and treatment at the US institution (OR 0.47, CI 0.34-0.65). CONCLUSIONS Despite major differences in baseline characteristics and care of cystectomy patients between the two study populations, peri-operative mortality rates proved to be comparable. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e74-e75 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Takahiro Osawa More articles by this author Cheryl T. Lee More articles by this author Takashige Abe More articles by this author Norikata Takada More articles by this author Khaled S. Hafez More articles by this author Jeffrey S. Montgomery More articles by this author Alon Z. Weizer More articles by this author Brent K. Hollenbeck More articles by this author Ted A. Skolarus More articles by this author Sachiyo Murai More articles by this author Nobuo Shinohara More articles by this author Todd M. Morgan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

SIRS at Admission Is a Predictor of AKI Development and Mortality in Hospitalized Patients with Severe Alcoholic Hepatitis.

Systemic inflammatory response syndrome (SIRS) is associated with an increased risk of hepatic encephalopathy, renal failure, and poor outcome in patients with cirrhosis; however, there is a paucity of studies on this entity for severe alcoholic hepatitis (SAH). To evaluate SIRS at baseline as a predictor of development of acute kidney injury (AKI) and mortality in patients with SAH. Consecutive in-patients with SAH (discriminant function ≥ 32) without AKI at baseline were followed up for the development and progression of AKI (AKIN criteria). Of the 365 patients (mean age 45.5 ± 9.5, 356 males), SIRS at baseline was present in 236 (64.6%). AKI developed in 122 (33.4%), of which 50 (40.9%) had progression of AKI. SIRS was associated with bacterial infections in 96 (40.6%) and in 140 (59.3%) occurred in the absence of proven infection microbiologically. The presence of SIRS predicted both AKI development (p < 0.001, OR 2.9, 95% CI 1.7-4.8) and AKI progression (p = 0.002, OR 3.27, 95% CI 1.48-7.21). Resolution of AKI also had a significant inverse association with SIRS (p = 0.001). High MELD score (p = 0.002, HR 1.1, 95% CI 1.02-1.09), in-hospital progression of AKI (p = 0.04, HR 1.54, 95% CI 1.003-2.38), and SIRS (p = 0.004, HR 1.98, 95% CI 1.25-3.1) were significant predictors of 90-day mortality (model 1), while high MELD score (p < 0.001, HR 1.1, 95% CI 1.04-1.12) and bacterial infections (p = 0.001, HR 1.8, 95% CI 1.27-2.6) were independent predictors of mortality in the second multivariate model (model 2). SIRS at admission predicts both the development of AKI and 90-day mortality in patients with SAH. This could definitely have a therapeutic and prognostic implication.

Mortality and Cost of Acute and Chronic Kidney Disease after Vascular Surgery

Both acute kidney injury (AKI) and chronic kidney disease (CKD) are common yet underappreciated risk factors for adverse perioperative outcomes. We hypothesize that AKI and CKD are associated with similar increases in 90-day mortality and cost in patients undergoing major vascular surgery. We used multivariable regression analyses to evaluate the associations between AKI and CKD and incremental 90-day mortality and hospital cost in a single-center cohort of 3646 adult patients undergoing major vascular surgery. We defined AKI using Kidney Disease: Improving Global Outcomes criteria as change in creatinine ≥ 0.3 mg/dL or ≥ 50% increase from the reference value. CKD was determined from medical history. Regression models were adjusted for demographic and socioeconomic characteristics, comorbid conditions, surgery type, and postoperative complications. The prevalence of kidney disease among vascular surgery patients is high with 49% of patients developing AKI during hospitalization and 17% presenting with CKD on admission. In risk-adjusted logistic regression analysis, perioperative AKI (odds ratio 2.2, 95% confidence interval 1.5-3.3) was the most significant predictor of 90-day mortality. The risk-adjusted average cost was significantly higher for patients with any type of kidney disease. The incremental cost of having any type of kidney disease ranged from $9100 to $19,100, even after adjustment for underlying comorbidities and other postoperative complications. Kidney disease after major vascular surgery is associated with significant increases in 90-day mortality and cost with the highest risk observed among patients with AKI regardless of previous CKD.

Distribution of interstitial pneumonia: a new radiological predictor of 90-day mortality after resection of lung cancer.

Surgery for lung cancer complicated by idiopathic interstitial pneumonia (IIP) is associated with a high rate of postoperative mortality. Thus, preoperative predictors of surgical mortality are needed to aid in the selection of suitable surgical candidates. The subjects of this retrospective study were 1625 patients who underwent resection of primary lung cancer between 2000 and 2012, 203 (12.5%) of whom were found to have IIPs. The following radiological findings were also evaluated: presence of honeycombing and the distribution (diffuse or localized) and extension (central extension or peripheral localized) of honeycombing or infiltration. We also investigated clinical factors and conducted multivariate analyses to identify the predictors of surgical mortality. The 30- and 90-day mortality rates were 0.5 and 1.4% overall and 1.6 and 6.4% in the IIP patients, respectively. Multivariate analysis revealed that a preoperative pO2<70mmHg (HR 15.3), diffuse distribution and central extension of interstitial pneumonia on computed tomography (HR 9.2), and operative blood loss (ml: HR 1.003) were significant predictors of 90-day mortality. Diffuse distribution and central extension of IIPs, as well as preoperative hypoxia and operative blood loss, were significant predictors of 90-day mortality.

Body temperature and mortality in patients with acute respiratory distress syndrome.

Little is known about the relationship between body temperature and outcomes in patients with acute respiratory distress syndrome (ARDS). A better understanding of this relationship may provide evidence for fever suppression or warming interventions, which are commonly applied in practice. To examine the relationship between body temperature and mortality in patients with ARDS. Secondary analysis of body temperature and mortality using data from the ARDS Network Fluid and Catheter Treatment Trial (n = 969). Body temperature at baseline and on study day 2, primary cause of ARDS, severity of illness, and 90-day mortality were analyzed by using multiple logistic regression. Mean baseline temperature was 37.5°C (SD, 1.1°C; range, 27.2°C-40.7°C). At baseline, fever (≥ 38.3°C) was present in 23% and hypothermia (< 36°C) in 5% of the patients. Body temperature was a significant predictor of 90-day mortality after primary cause of ARDS and score on the Acute Physiology and Chronic Health Evaluation III were adjusted for. Higher temperature was associated with decreased mortality: for every 1°C increase in baseline temperature, the odds of death decreased by 15% (odds ratio, 0.85; 95% CI, 0.73-0.98, P = .03). When patients were divided into 5 temperature groups, mortality was lower with higher temperature (P for trend = .02). Early in ARDS, fever is associated with improved survival rates. Fever in the acute phase response to lung injury and its relationship to recovery may be an important factor in determining patients' outcome and warrants further study.

Abstract No. 348 - Predictors of ninety day mortality in post TIPS patients

Purpose The impact of clinical and cardiovascular parameters on post TIPS survival has been poorly defined. This study aims to evaluate the role of multiple factors, including race, liver pathology, pre-TIPS MELD, change in MELD post-TIPS (ΔMELD), and EKG and echocardiographic parameters, as predictors of 90 day survival after TIPS. Materials and Methods A retrospective institutional review was performed on 121 consecutive patients that underwent successful TIPS placement between January 2006 and December 2011. MELD was calculated within 30 days prior to TIPS and also 15 to 45 days after TIPS. Echocardiographic and EKG parameters were obtained within 6 months before and after TIPS. Race, procedural indication, and liver pathology were also documented. Univariate and multivariate analysis was then performed to look at 90-day mortality predictors. Results 96 of the patients had a minimum of 90 day follow-up, and calculations were based on these patients. Mean age was 55. 55% of patients had HCV and 49% had alcohol related liver disease. Pre and post-TIPS MELD scores were 15.4 and 17.6, respectively. On EKG, mean pre and post TIPS QTc were 461 and 469. 18 patients (19%) died within 90 days of the procedure. In univariate analysis, pre-TIPS MELD (OR=1.33, p 4 post-TIPS (OR=1.34, p=0.001), post-TIPS MELD >18 (OR=8.72, p 480 (OR=7.00, p=0.01) were statistically significant predictors of 90-day mortality. In multivariate analysis, pre-TIPS MELD (OR=1.59, p=0.004) and ΔMELD >4 post-TIPS (OR=1.4, p=0.006) were the only statistically significant predictors of 90 day mortality. Sex, race, age, liver pathology, procedure indication, and echocardiography were not statistically significant predictors in 90 day mortality. Conclusion Pre-TIPS MELD and ΔMELD >4 post-TIPS are strong predictors of 90-day mortality. Other factors such as race, cardiac parameters, procedure indication, and liver pathology are unreliable in predicting 90 day mortality.

Aggregate risk score for predicting mortality after surgical biopsy for interstitial lung disease

In order to develop a practical risk score for 90-day mortality following surgical lung biopsy (SLB) for interstitial lung disease (ILD) we reviewed 311 consecutive patients undergoing SLB for ILD between 2002 and 2009. Postoperative complication, 30-day and 90-day mortality rates were 11.5%, 9% and 10.6% respectively. Univariable and multivariable analyses, validated by bootstrap statistics, were used to identify factors associated with 90-day mortality. A scoring system was developed by proportionally weighting the regression coefficients of the significant predictors of 90-day mortality: age >67 (P < 0.0001, weighted score 1.5), preoperative intensive care unit (ICU) admission (P = 0.006, weighted score 2), immunosuppressive treatment (P = 0.004, weighted score 1.5) and open surgery (P = 0.03, weighted score 1). Patients were grouped in four classes showing incremental risk of death at 90 days: class A, score 0 (2%); class B, score 1-2 (12%); class C, score 2.5-3 (40%); class D, score >3 (86%); P <0.0001). SLB entails a considerable surgical risk with an overall 90-day mortality around 10%. We were able to develop a practical risk score which, if validated by other independent studies, can be easily used to stratify the risk of SLB candidates and assess the cost-effectiveness of this procedure.

Predictors of early mortality after radical nephrectomy with renal vein or inferior vena cava thrombectomy – a population‐based study

Study Type - Prognosis (cohort) Level of Evidence 2a. What's known on the subject? and What does the study add? Surgical volume has been well established as a predictor of outcomes for several complex surgical procedures, yet few studies have evaluated this relationship with regards to radical nephrectomy with either renal vein or inferior vena cava thrombectomy. In addition, most published literature consists of single-institution series from centres of excellence. We performed a population-level analysis and identified surgeon volume as a significant predictor of short-term mortality for this procedure. Such findings have potential implications regarding future policy and regionalization of care. • To study the short-term mortality associated with radical nephrectomy with renal vein or inferior vena cava thrombectomy and the variables associated with this adverse outcome. • Using the Ontario Cancer Registry, we identified 433 patients in the province of Ontario, Canada undergoing radical nephrectomy with venous thrombectomy between 1995 and 2004. • We determined mortality rates at postoperative days 30 and 90. • Other variables analysed include pathological tumour characteristics, surgeon graduation year, hospital/surgeon academic status, surgery year and hospital/surgeon volume. • We used multivariable logistic regression to assess outcomes. • Overall mortality was 2.8% (30-day) and 5.8% (90-day). • Surgeons performing a single nephrectomy with venous thrombectomy performed 14% of the cases and had the highest 30-day (6.7%) and 90-day (10%) mortality. The mortality rate for surgeons performing more than one surgery was 2.1% (30-day) and 5.1% (90-day). • In recent years, this procedure was performed more commonly by the highest volume surgeons - 67% of cases in 2004 vs 40% in 1995. • Significant predictors of 30-day mortality included procedure year and low surgeon volume. • Significant predictors of 90-day mortality included procedure year, low surgeon volume, left-sided tumour and increasing hospital volume. • For radical nephrectomy with venous thrombectomy, surgeon volume predicts short-term mortality, emphasizing the importance of experience in patient outcome. • Despite a shift towards high-volume surgeons, 13.8% of cases continued to be performed by low-volume providers. • If these results are confirmed in other jurisdictions, radical nephrectomy with venous thrombectomy should be regionalized and performed by surgeons who manage these cases regularly.

Predicting the Probability of 90-Day Survival of Elderly Patients With Bladder Cancer Treated With Radical Cystectomy

Despite the increased morbidity and mortality of radical cystectomy in elderly individuals with bladder cancer numerous studies show that surgery can provide a survival benefit. We sought to better identify patients at substantial risk for postoperative mortality. We evaluated 220 consecutive patients 75 years old or older treated with radical cystectomy for bladder cancer at a single institution from 2000 to 2008. The analytical cohort comprised 169 patients with complete preoperative data available. A Cox proportional hazards model was used to determine the value of precystectomy clinical information to predict 90-day survival after radical cystectomy. Results were used to create a nomogram predicting the probability of 90-day survival after radical cystectomy. The model was then subjected to 200 bootstrap resamples for internal validation. Of the 220 patients 28 (12.7%) died within 90 days of surgery. Older age (HR 2.30, 95% CI 1.22-4.32) and lower preoperative albumin (HR 2.50, 95% CI 1.40-4.45) were significant predictors of 90-day mortality. We developed a nomogram based on patient age, clinical stage, Charlson comorbidity index and albumin to predict the likelihood of 90-day mortality with 75% accuracy. Internal validation showed a bootstrap adjusted concordance index of 71%. We developed a nomogram that provides individualized risk estimations to predict the probability of 90-day mortality, potentially enhancing preoperative counseling and providing clinicians with an added tool to individualize treatment decisions in this challenging patient population. These data suggest that albumin is a strong predictor of postoperative mortality and show the importance of assessing this variable before surgery.